Happy Monday! This week's article falls into the category of "classics": an interesting, controversial, and thought provoking experiment that might cause us to question some of our foundational ideas about mental health. On Being Sane in Insane Places, by D. L. Rosenhan (Science 179: 250-258, 1973) examined what might happen if a healthy individual presented, claiming vague symptoms and seeking admission to a psychiatric hospital. Although it was (rightly) criticized as lacking realism, since the "patients" were intending to deceive psychiatrists through their subjective reports, I think that reading this still might make us pause and ask "How do we know what we think we know?" (For one of the major critiques, see Spitzer, Journal of Abnormal Psychology, 84(5): 442, 1975, if you want to dig deeper.)
I found the observations of how patients and staff interactions very interesting as well. Although there are many differences between the psychiatric institutions of 40 years ago and our current inpatient units, I think there is still a real danger that we might easily dismiss or minimize patients' experiences. The subjects of this experiment reported boredom, invasion of privacy, and dehumanization--to say nothing of loss of autonomy--and I think these are still relevant experiences of our patients today. What have you noticed on our units that is similar? Do we really treat patients "better" today? How do we ensure that patients' humanity and dignity is maintained, in spite of their illness and potential endangerment of self or others? It's often been said that the only difference between "Us" and "Them" is that one has the keys. Considering this might cause us to consider how it feels to be on the other side of that door.
Rosenhan
The first thing that struck me when reading the article was how different the inpatient psychiatric system was when the article was written. The patients only complained of auditory hallucinations and they were admitted to the inpatient floor. In addition, they kept one of the patients 52 days for this complaint, after which he supposedly "acted normal" for the rest of his stay.
ReplyDeleteCurrently, I think we all have patients that "act sane" while on the floor, but one of the large unknowns for providers, and one of the important considerations that providers make when deciding to discharge a patient, is the question of how that patient was acting and living when outside of the hospital. I imagine that this question played into the extended length of stay for some of these patients 40 years ago.
Unfortunately, I think the patient experience described in the article is similiar in many ways today (at least based on the description given) to what it was 40 years ago.
One of the first things that struck me reading this article was the question: "do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them?" The way I interpreted this had me thinking of the treatment team's judgments, preconceptions, and attachments to agenda. I often wonder how much these are contributing to the decisions made in psychiatric care: it seems that many times throughout the day I will show up on a floor and hear all sorts of chatter about who patient's remind staff of, what patient's act like based on the staff members view of ordinary, etc. It also draws my attention to the idea that what is abnormal in one culture (even one individual's life) may be seen as normal in another culture. I appreciate the advice of Dr. Oakman regarding the approach to inpatient: safety, stabilization, and making a plan. This seems a good framework to keep the team committed to the task, focused on what is important. However so much of what we learn in training is based on agenda: compile symptoms, follow checklists, make a diagnosis, consider medication, etc. It seems already that very little attention is paid to the idea of labeling a patient, much like we would label a criminal a felon potentially. As in the article, a pseudopatient is d/c'd and must naturally be in "remission" but to the institution the patient was possibly never sane. The above comments I make bring to my attention the idea of mindfulness, and again, to echo Dr. Oakman, taking compassion breaks. What is the impact of our actions on others? What is his/her suffering and what does that look like? How do we experience interdependence in a medical provider-patient relationship? What responsibility do we have as medical providers to the relationship our patient has with society where labels like "sane" and "insane" have a big impact on how people are treated?
ReplyDeleteThe Rosenhan experiment makes me wonder, "How many people are sane but recognized as insane in our psychiatric institutions?" I encounter criminal cases of the perpetrator claiming insanity/mental illness to avoid the criminal consequences and ultimately gets away with the crime. This is upsetting, but unarguably it is a challenge to distinguish the sane from the insane in psychiatric hospitals.
ReplyDeleteAs I read this article, I imagined how I would have reacted if I was a pseudopatient in the current inpatient units. Unfortunately, I agree with many of the negative experiences raised in this article: the powerlessness, depersonalization, mortification, and self-labeling. Although we try to minimize the extent of these impacts, it is prevalent. I remember a patient, who was regularly recorded her thoughts and questions in a notebook. I thought it was a nervous habit associated with schizophrenia or that it was how she coped with adapting to the new environment, and never took the time to elaborate on it. Whereas, if this was in a different setting, I may have shown more interest and asked. I was not being callous. In retrospect, it was an innocent formulation based on the diagnoses/labels and observations attributed to the environment.